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Jill Maben: 'We need strong evidence to improve standards'

8 January, 2013

Hearsay, common knowledge and instinct are not enough. Strong evidence is needed if we are to make the case for ensuring staff wellbeing, says Jill Maben

A three-year study by the National Nursing Research Unit, reporting links between staff wellbeing and patient experience, was recently reported on nursingtimes.net (“Nurse wellbeing has ‘direct impact’ on patient care”, http://tinyurl.com/czz2sgv). Many readers responding online were not impressed, suggesting they could have “concluded this study in 3 seconds” and wondered: “How much of a slice of the NHS pie did these numpties get to tell us something that we already knew?”

As the lead “numpty”, I can tell you that the way research is funded in the UK (by the National Institute for Health Research) does not take away from the NHS pie and from frontline staff. And, while I totally sympathise with the frustration felt by nurses responding, I’m depressed by some of the hostile comments, and the failure to see this research as a useful tool to argue for the resources and support that staff need to do a very difficult job.

“The fact that we found evidence of a link between staff wellbeing at work and patient experience is important”

I care passionately about how best to support staff in practice to deliver high-quality care – we are on the same side – yet, when nursing research with important policy relevance gets publicity, there are those who feel the need to insult those undertaking the research. In doing so, they miss the important wider picture.

In the current climate what we – together – need most is to argue for the resources required to deliver high-quality care. To do that, we need evidence. It is not enough for us to know instinctively that “happy staff equals happy patients”. We need clear evidence that it is true for a specific team of staff delivering care to a group of specific patients.

Our study set out to examine how and why staff wellbeing at work matters, not just to staff but to patient care too. We wanted to see how it differed between areas, with different patients, different staff and different degrees of emotional labour. We therefore undertook detailed fieldwork in eight case studies – four in the community (including a rapid response team and adult community nursing) and four in the acute setting (including acute admissions and care of older people).

Our study involved more than 200 hours of direct care observation, more than 100 patient interviews and nearly 500 patient surveys, interviews with 55 senior managers, surveys of more than 300 staff and 86 staff interviews at four trusts. The majority of our respondents were nurses, but some were doctors and allied health professionals.

The fact that we found evidence of a link between staff wellbeing at work and patient experience is important. One of our key findings is that in all settings it was not the wider organisational climate that mattered most to staff (as evidence outside healthcare suggests), but that the local team climate is crucial – what participants called “family at work”.

Our evidence supports calls for investment in unit level leadership to create well-functioning teams in challenging contexts. Our research supports the case for staff wellbeing champions to be embedded in NHS trusts at board level so that staff experience becomes as important as patient experience for the board. Because we now have evidence that the two are so closely intertwined, we can argue that looking after staff is key to improving experiences for patients.

This study is now part of the evidence base. As nurses, we can and should use it to challenge organisations with poor practice.

The research has been presented to the select committee on public service and demographic change regarding the quality and performance of the health and care system for older people. It is up to all of us – nurses and researchers – to use it to help secure improvements in our working lives and to ensure high-quality care for our patients.

Jill Maben is chair in nursing research at the National Nursing Research Unit, King’s College London

Readers' comments
(63)

Staff well being is directly related with an ability to "do the job" to a standard which provides a level of personal satisfaction.

Continuing and excessive demand, a lack of resource and a refusal by management to listen is a sure recipe for disaster.

Yet more numpties employed within NHS organisations (no doubt with inflated salaries) are not required.

Why not just require the army of people employed in so HR departments to do their job? -----guess they are to busy planning the next trance of RN redundancies!

I note not much is said about Senior Nurse Managers --- a group which has done more to destroy "well being" and ensure a lack of moral amongst nurses than any other. Let me remind you these are the people fronting the management rush to reduce, downgrade and deskill the nursing profession.

A very interesting article. As a student nurse, I get the opportunity to change practice placement areas every 10-12 weeks and on the very first day of a placement it is clear to see what a 'family at work' is, and what it is not. If I, as a student can sense this beginning placement on a new ward, I am certain it will reflect on patients, and obviously the research by the NNRU now supports this.

It has been evident from placements that in critical care environments where staff to patient ratios are higher that patient care is excellent, no rock is left un turned, paperwork is completed and the nurses are getting home on time. But of course this is common knowledge.

The difficulty is exactly how you support staff well-being in the current climate. Nurses are constantly crying out for more colleagues and more resources. Will staff satisfaction ever be improved if these aspects are not looked at? Will staff well being champions be forever told that more resources are needed?

I hope the findings of the research can be implemented to better support nursing staff, so that staff well-being and patient care and satisfaction is both improved.

Oh dear - why are we so often our own worst enemies! I was upset by the initial reaction to this research in NT and Jill has sensibly responded yet still someone is arguing this research won't help. Yes HR should be doing their job - ours is woefully awful - for example only in Nov 2012 did they issue the contract for my current post which started on 1.4.12 and ends 31.3.13! But HR can't sort out inadequate ward level leadership and in my experience (intensive care) this can make or break many things - some of which Jill and team's research clearly illustrates. Re the student comment above unfortunately intensive care is not immune - ours is very short of staff, people are constantly being asked to do extra hours, working when they really shouldn't because not well, there are far too few experienced nurses partly because experienced staff have had enough and left, over many years there has been downgrading so we have fewer staff on band 6 and 7, clinical staff are doing admin which should be done by a ward administrator/secretary, quality of patient care (quite apart from quality of staff care) is suffering. Staff are ground down and lacking the energy to stand up and present the evidence that would improve things. The problems seem overwhelming but I know that presenting the research evidence for change can work - I have done it before and achieved improved staffing levels as a result but it takes time and energy to do that and there is no time at work, though there should be because it is part of monitoring quality of care. Plus it requires constant vigilance to pick up on slippage and without good team leadership this doesn't happen. But somehow we all have to try and do something and use all the research evidence we can find to support what we know should be happening to improve care. Put in writing to your manager when you can't achieve the level of care you know should be being given, fill in incident reports for omissions in care (not just things that went wrong) and write this in patients' care plans, speak to your director of nursing - don't give up and be silenced, think of Stafford and keep reporting things. NB if you haven't seen the Francis Report it can be found here: http://www.midstaffsinquiry.com/pressrelease.html

Oh dear - why are we so often our own worst enemies! I was upset by the initial reaction to this research in NT and Jill has sensibly responded yet still someone is arguing this research won't help. Yes HR should be doing their job - ours is woefully awful - for example only in Nov 2012 did they issue the contract for my current post which started on 1.4.12 and ends 31.3.13! But HR can't sort out inadequate ward level leadership and in my experience (intensive care) this can make or break many things - some of which Jill and team's research clearly illustrates. Re the student comment above unfortunately intensive care is not immune - ours is very short of staff, people are constantly being asked to do extra hours, working when they really shouldn't because not well, there are far too few experienced nurses partly because experienced staff have had enough and left, over many years there has been downgrading so we have fewer staff on band 6 and 7, clinical staff are doing admin which should be done by a ward administrator/secretary, quality of patient care (quite apart from quality of staff care) is suffering. Staff are ground down and lacking the energy to stand up and present the evidence that would improve things. The problems seem overwhelming but I know that presenting the research evidence for change can work - I have done it before and achieved improved staffing levels as a result but it takes time and energy to do that and there is no time at work, though there should be because it is part of monitoring quality of care. Plus it requires constant vigilance to pick up on slippage and without good team leadership this doesn't happen. But somehow we all have to try and do something and use all the research evidence we can find to support what we know should be happening to improve care. Put in writing to your manager when you can't achieve the level of care you know should be being given, fill in incident reports for omissions in care (not just things that went wrong) and write this in patients' care plans, speak to your director of nursing - don't give up and be silenced, think of Stafford and keep reporting things. NB if you haven't seen the Francis Report it can be found here: http://www.midstaffsinquiry.com/pressrelease.html

'Our study involved more than 200 hours of direct care observation, more than 100 patient interviews and nearly 500 patient surveys, interviews with 55 senior managers, surveys of more than 300 staff and 86 staff interviews at four trusts. The majority of our respondents were nurses, but some were doctors and allied health professionals.'

Jill, does that cover 'enough of the potential variables' ? Or, is it just 'scratching the surface' towards an uncontestable study ?

And this is fascinatiing:

'One of our key findings is that in all settings it was not the wider organisational climate that mattered most to staff (as evidence outside healthcare suggests), but that the local team climate is crucial – what participants called “family at work”.'

Well - if it is raining everywhere else in the country, but not in your locality, you don't get wet, do you ? How could it be anything other than 'the local team climate' which has the major effect ?

it doesn't matter how much evidence is put forward, this unelected government aren't listening. They may glance at it and then say 'anyway, where were we?' They have their own agenda and nothing is going to get in their way least of all nurses and quality patient care and services except for those who can afford it.

I agree with what you say about the government. They do have their own agenda. However, that's where nurses themselves come in. The problem is that the nursing profession will not stand up to this (or any other government). That is not the fault of the researchers or the study itself, and that has to be recognised.

"Our study set out to examine how and why staff wellbeing at work matters"

Interesting stuff (to me anyway!)Look up and read a book on the internet called "Happiness is 9-5". Its not a nursing book but its fab at looking at how being happy at work matters - the implications into our own areas could be huge.

However, I do note that we as nurses shouldn't just whinge about things but do something about it - which we probably do at our own areas, but until we come together and hit the fundamental root causes of our struggle (Goverment, bad Managers, staff shortage, training etc...) then we will continue to struggle!

I agree it disappointing that there are many nurses who still do not understand the importance of nursing research and the positive impact it could have on the profession. We just need to do more of it. The case for higher staffing ratios will never be won by directing blame at senior nursing colleagues who are invariably fire fighting with a limited budget which they do not set

I am looking forward to this research leading to improved staffing numbers, better staffing-patient ratios,improved staff morale and health and improved working environments. All these things are vital.

As for critical care - it's just the same as everywhere else, short-staffed, rushed off our feet. No-one gets home on time and paperwork is not always completed.Get real people.

Update: it’s working! The petition demanding an investigation into lives put at risk by private health companies is growing fast with over 90,000 signatures so far. Thanks so much for being part of it.

If we can get the petition to 100,000, we will deliver it by hand to a powerful committee of MPs. There’s a great chance that it will convince them to launch a high-profile investigation into private health companies, just like they recently did for tax-dodgers.

Can you help by spreading the word to your friends and family? Please forward this email and ask friends to sign the petition here: https://secure.38degrees.org.uk/GP-out-

As you point out, politicians are far from 'neutral' when they select the research they will use as back up: and normally, they do use it as back up, not to actually define their policy (they know what they want to do, then find some 'evidence' to fit - often going to absurd lengths, to shoehorn something that clearly doesn't properly fit !).

It's not up to the government to use the research. It's up to nurses to use it to back THEIR case. More research is needed. But the bigger issue is the complete lack of ability within the nursing profession to show a united front and form a coherent and effective case against the problems we currently face in health care in this country.

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